Esketamine-Based Opioid-Free Anesthesia in Laparoscopic TAPP Repair

Key Takeaways

• Esketamine-based opioid-free anesthesia was associated with slightly higher 24-hour QoR-15 scores, and postoperative recovery quality was characterized as noninferior.
• Lower pruritus and less vasopressor use were reported, while hypotensive episodes were described only as tending to be fewer.
• Lower pain scores on coughing were reported at 24 hours and 48 hours after surgery.

Adults undergoing elective laparoscopic transabdominal preperitoneal repair were randomized to esketamine-based opioid-free anesthesia or an opioid-based regimen, with early recovery favoring the opioid-free approach. At 24 hours, the between-group median difference on the QoR-15 was 2 points, and postoperative recovery quality was characterized as noninferior. In this minimally invasive hernia procedure, the comparison tested an esketamine-based opioid-free strategy without intraoperative opioids. The opioid-free group had a slightly higher 24-hour recovery score within the trial's noninferiority framework.

This prospective, randomized, double-blind, noninferiority trial enrolled 126 adults scheduled for elective laparoscopic TAPP repair and assigned them 1:1 to two anesthetic strategies. Each group included 63 patients, with esketamine 0.5 mg/kg at induction and 0.4 to 0.5 mg/kg/h for maintenance in the opioid-free arm. The opioid-based arm used sufentanil 0.4 microg/kg at induction and remifentanil 0.1 to 0.2 microg/kg/min during maintenance. The primary endpoint was the QoR-15 at 24 hours after surgery, with a noninferiority margin of -8, while secondary outcomes included pain scores, rescue analgesia, sleep quality, and safety measures.

For the primary outcome, the 15-item Quality of Recovery score at 24 hours was higher in the opioid-free group than in the opioid-based group. Median scores were 129 [125 to 132] and 127 [123 to 130], respectively. The median difference was 2, with a 95% CI of 0 to 4 and P=0.014. The investigators concluded that postoperative recovery quality with esketamine-based opioid-free anesthesia was noninferior to the opioid-based regimen in this surgical setting.

Secondary findings included lower pruritus incidence with opioid-free anesthesia and reduced vasopressor use, with P=0.027 and P=0.012, respectively. Hypotensive episodes were described as tending to be fewer in the opioid-free group, although the comparison did not show a definitive between-group difference. Pain scores on coughing were lower with opioid-free anesthesia at 24 hours and again at 48 hours, with P=0.002 and P<0.001. Sleep quality and rescue analgesia were listed among secondary outcomes, but those results were not provided in the abstract excerpt.

The findings centered on recovery quality after minimally invasive hernia repair rather than a broader perioperative endpoint set. Within that scope, esketamine-based opioid-free anesthesia was associated with a slightly higher early recovery score and a favorable pattern across several symptom measures. Postoperative recovery quality was characterized as noninferior versus opioid-based anesthesia in laparoscopic TAPP repair.